Orbital-frontal delayed hemorrhagic contusions: clinical course and neurosurgical treatment protocol

Delayed posttraumatic hemorrhage into the underlying contusion could cause significant elevation of intracranial pressure (ICP) and dramatic clinical and radiographic deterioration. The authors identified a subgroup of young patients with initial mild/moderate head injury, who presented with orbito-frontal and temporal tip minimal punctate contusions, which within 24 hours, expanded into dramatically larger noncoalesced hemorrhagic contusions.

Four consecutive patients within a 13-month period admitted to our institution with the above radiographic picture are presented and their clinical and treatment courses compared.

After observing the relentless downhill course of two earlier patients treated for the control of ICP, our treatment protocol changed to early prophylactic intubation and moderate hyperventilation, insertion of an intraventricular catheter for ICP monitoring, hyperosmolar therapy with mannitol, sedation, chemical paralytics, and eventually pentobarbital for control of increased ICP. These interventions were mostly taken before the radiographic evidence of contusion blossoming and dramatic clinical deterioration. These two subsequent patients had a prolonged course of intubation and ICP problems requiring tracheostomy placement. The clinical outcome was excellent, however, with both patients decanulated from the tracheostomy within 6 weeks, and both returned to relatively normal premorbid functions.

Although the series consists only of four consecutive patients with similar radiographic appearances, the authors advocate ultra-early aggressive medical treatment for this subgroup of patients with orbito-frontal contusion, prior to dramatic clinical and radiographic deterioration, as the outcome difference could be great.